I have presented at many conferences this year. Already at this point you may think, so what! My point is this. Even though it’s a challenging time in global health, the commitment of conference organisers to reach out and seek inputs from the range of IPC talent that exists across the world, has remained a constant. These have been amazing experiences, and the overwhelming mood for me is the power of the collective – learning together and importantly, solidarity! One of the highlights of my personal learning experience was reconnecting with colleagues at the Infection Control Africa Network conference in Cape Town in July and hearing about the important work to elevate the status of cleaners and to recognise their critical role in IPC – I will come back to this at the end! Another highlight was Qatar Patient Safety Week congress in Doha in September, and the depth of sharing around quality, safety and IPC implementation and improvement.
This International Infection Prevention Week, IPC solidarity is important – perhaps now more than ever. You have maybe seen me post on LinkedIn about this alongside others.
And that’s why this post is about two important topics – both of which are in support of IPC colleagues around the globe, and those often invisible, while vital healthcare workers – cleaners. You may have also seen a new # in this week of Clean Hospitals Day? – #DoYouKnowYourFacilityCleaner
Firstly, the barriers IPs face day to day can be overcome and Elsa and Anna can help
Although the vast majority of conference presentations I have heard this year were concerned quite logically with improvement, what floated to the surface was the articulation of the many barriers to achieving goals and targets across patient safety, quality of care and IPC.
And as someone whispered in my ear at Qatar Patient Safety Week congress – “we must ensure we don’t end up falling down a spiral where we only highlight barriers.” Barriers can be the start of the journey but it is how they are then used to help find solutions that can support planning for implementation and improvement.
This all made me think, again. Made me think about what we actually feel when we talk about all these known barriers, barriers that I have identified with country colleagues over the years during many pieces of implementation and improvement work. Made me think even more about what I heard at the conferences from esteemed leaders and how we can tip the scales to be more solution focused together.
Interestingly, A systematic review on Barriers and Facilitators of Health Care Workers’ Compliance with Infection Prevention and Control Practices in Health‑care Facilities was published this year, which highlighted two main themes relating to the institutional factors associated with compliance and those factors that are at the level of the individual. Key barriers were outlined as lack of knowledge and training, time constraints, workload, inadequate resources, and cultural and behavioural factors.
Reading this paper made me jump back 15 years to consider WHO’s Guidelines on hand hygiene in health care – the first ever global guidelines on hand hygiene. In those guidelines, details of likely barriers to hand hygiene are outlined. In almost every WHO guideline or practical guide to implementation issued since 2009 there is a list of barriers, and importantly, enabling factors and examples of success. The aforementioned systematic review also outlined key facilitators, including leadership and management support, education and training, adequate resources, and monitoring and feedback, all of which resonate with improvement approaches, including the multimodal improvement strategy for hand hygiene. The toolkit associated with the WHO guidelines was indeed at the core of addressing all of the identified barriers. It included, for example, assessment tools to address infrastructure, knowledge and perceptions, placement of alcohol handrub, training resources including videos, etc.
I decided to map some of the barriers presented in the WHO Guidelines for hand hygiene in healthcare, against information presented within the recently launched WHO Guidelines on hand hygiene in communities (launched on 15 October 2025) – see the table below.
From this mapping, and from everything I have heard at conferences, I believe we could conceive an informed, short checklist of all the common barriers that are known to us, around the world, and use this to remind ourselves that they are indeed common to much of what we do across all of IPC. This is not to take away from using evidence-based papers, guidelines and implementation manuals, but to allow us to do a check – a sanity check. Essentially, to make sure that we don’t let the never-ending pursuit of identifying barriers hold us back. Instead that we acknowledge those that prevail and use them to keep on the journey of implementation and improvement – a journey that never actually ends for IPs.
So, identifying barriers is important – but it should not paralyse us – the act of identifying them is part of a journey. And it’s not unique to health care. In real life and even in the movies, this process can hold the key to success. I recently watched the movie Frozen II (again!). Frozen II is really a story about overcoming barriers and all of the uncertainty that surrounds this. Elsa and Anna set out to protect their kingdom. At first, they don’t have all the information they need, and there are conflicting views. Only when they work together, share knowledge and recognise the situation can they solve the problem. In health systems, IPC plans can fail for the same reasons — when there’s different perceptions of the problem or not enough recognition of the benefits of change, implementation and improvement will be challenging – and the journey might end up having a very unhappy ending.
| WHO Guidelines on hand hygiene in healthcare (2009) – summary of listed barriers | WHO Guidelines on hand hygiene in community settings (2025) – summary of information presented as barriers | |
| Motivation | Skin irritation, types and availability of hand hygiene agent Access to supplies, location of sinks | Inadequate access to materials |
| Working day (week versus weekend) Patient:nurse ratio Lack of time | Time prioritization (reflective motivation) Understanding of time required to achieve progress | |
| Patient vulnerability and patient infection risk/activity infection risk | Vulnerable people in the community | |
| Professional status (i.e. doctor) Understaffing/overcrowding | ||
| Behaviours | Interference with relationships (HCW:patient) | Understanding of what drives or hinders behaviour |
| Peer behaviours | Lack of behaviour change theories | |
| High workload, too busy Forgetfulness and interruptions Wearing of PPE | Cognitive, psychological, environmental and sociocultural factors | |
| Gender and the workplace | Understanding of gender related roles | |
| Strategies and fiscal | Lack of knowledge | Lack of tailored strategies |
| Lack of guidelines and knowledge, information/ evidence and perceived benefit, lack of awareness | Lack of policy, legal regulatory or fiscal measures | |
| Lack of recognition of benefit – scepticism and disagreement on recommendations | Lack of perceived benefit/recognition | |
| Lack of rewards / encouragement | Lack of timely stakeholder involvement – community engagement | |
| Understaffing | Lack of or competition for funds |
Mapping just a small part of these two sets of hand hygiene guidelines was interesting. It is clear that there are common themes across the barriers presented, namely – motivation, behaviours, strategies. These themes were driven mainly by the terminology in the new Guidelines, with the many contained within the 2009 Guidelines mapped to these themes. It is important to note that that new WHO Guidelines for the community do not replace the 2009 Guidelines,
Considering all of the barriers listed in the table – do the barriers resonate with those that you face in IPC? Do you take a systematic approach to identifying potential barriers and how to address them when you plan to implement IPC improvements?
#DoYouKnowYourFacilityCleaner
So, back to the topic of cleaning and cleaners. Julie Storr has shared with me a couple of extremely impactful quotes that she gathered from esteemed colleagues within her conference experiences, and which should make us all want to support #DoYouKnowYourFacilityCleaner
- “I spent the day working as a cleaner in our large teaching hospital. I suddenly realised that cleaners have a superpower. I became invisible. Nobody talked to me or seemed interested in what I was doing or that I even existed.”
(UK paediatric surgeon, 2023)
- “Before the first scalpel is sterilized, before the first patient is admitted, someone has already started saving lives. Not with stethoscopes or prescription, but with a mop, gloves and a silent commitment to safety. This is the story of the invisible gatekeepers of healthcare: the cleaners.”
(ICAN conference, 2025, Unrecognized gatekeepers in healthcare by Elizma de Klerk)
Getting to know your facility cleaner should not just be a tokenistic gesture. Cleaners are and should be part of the team and certainly not invisible. Making cleaners feel “seen” is one part of supporting implementation of IPC best practices. As Rock et al (2016) quite nicely stated “Adequate microbiologic disinfection of surfaces can be achieved with appropriate cleaning procedures; however, implementation and adoption of these practices in real world settings has been difficult and incomplete.”
All of this holds true today and reminds us again that barriers can be the start of the journey but it is how they are then used to help find solutions that can support planning for implementation and improvement, for all aspects of IPC.